HomeMy WebLinkAboutApp-Permit-ComplianceT i"CP'➢IV4 SW 1 6-1 V"d"t L- 1 i -! L91.e6" 1.
No. / 1146 ROUTE 20 FEE
80. YARMOUTH, OUTH, %ifs 026-04
•
Board of Health,044re7,/-//,Am.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade (/Abandon(1 ) - ❑ Complete System ❑ Individual Components
Location z � �
Owner's Name
ef"-
Map/Parcel#/,/, fes- ,,�
Address
Lot#►� ai,J
Telephone#
Installer's Name 4�-2115- , ��
Designer's Name
ji ;;7.;4 S-aAj
Address .3��ge4 94i
Address
., Q�ad�
Telephone#
Telephone#
2? S-3 — 177
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
A Na V'
No. of persons
Lot Size
.0/40J sq. ft.
Garbage grinder (4
Showers ( ), Cafeteria ( )
Other Fixtures
r Design Flow (min. required Calculated design flow s3 Design flow provided c�4 gpd
Plan: Date Number of sheets !� Revision Date
.46 Title
Description of Soil (s) _
Soil Evaluator Form No.
A
REPAIRS OR ALTERATIONS
�7' , Y.
104Name of Soil E aluatorWO Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to lace theme system inoperation until a Certificate of Compliance has be n issued by the Board of Health.
Signed C!�� Date
Inspections
tk
t
No.�
COMMONWEALTH Of MASSACHUSETTS FEE
r. a C� Sr
Board of Health,4/` MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: v 5.
at
has been installed in accordance with the provisions f 310 CMR 15.00 ( tle 5) and the proved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer �.
Designer: l/p Vi a-.,Xz Inspector: Date: /��% �.•�
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
FEE—
COMMONWEALTH OF MASSACHUSETTS
J Board of Health MA.
DISPOSAL SYS EM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair ( ) Upgrade (Abandon ( ) an individual sewage disposal system
at �.�'/�"'� 1.��a� as described in the application for
Disposal System Construction Permit No. 9 dated f
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date'?— `��� ( ?Board of Health